RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER

PHYSICAL THERAPY DEPARTMENT

RANCHO R.O.A.D.M.A.P.
(Recommendations for Orthotic Assessment, Decision-Making, And Prescription)

Lower Extremity Orthoses: Overview

Page 1 of 4

Goal: Choose appropriate orthosis given patient's clinical picture and/or impairments.
Patient Population: Persons with neurological impairments who require orthoses to ambulate or to perform upright
functional activities
In addition to the impairments indicated, before ordering orthoses, factors should be considered such as whether the
patient has:
• Sufficient ROM in Lower Extremity joints to align segments
• The ability (including cognition) and desire to meet ambulation goals
• Adequate cardiovascular endurance and adequate Upper Extremity (UE) and Lower Extremity (LE) strength for the
intended activity, i.e. ambulation
• Sufficient strength to advance the limb

References:
Patient has:
Significant gait deviations1, 1. The Pathokinesiology
lower extremity weakness, Service and the Physical
impaired proprioception at the knee or ankle, Therapy Department,
or ankle plantar flexor spasticity / varus Rancho Los Amigos National
Rehabilitation Center:
Observational Gait Analysis,
Downey, CA, Los Amigos
Research and Education
Institute, Inc., 2001.

Patient has: 2. Lower Extremity

< 3+/5 quadriceps strength Orthoses: Ankle Foot
and/or impaired/absent Orthosis, Lower Extremity
proprioception on test limb? Orthoses: Long Leg
Orthoses, Lower Extremity
Orthoses: Patient
Involvement in Decision
about Intervention, Rancho
Yes Los Amigos National
Rehabilitation Center, 2000,
2003.
See algorithm:
Lower Extremity
No Orthoses: Long Leg
Orthoses2
See Algorithm:
Lower Extremity Orthoses:
Patient Involvement in
See algorithm: Decision about Intervention
Lower Extremity
Orthoses: Ankle Foot
Orthosis2

DISCLAIMER STATEMENT
"The algorithm/care described in this document does not represent the only medically
acceptable approach. Each clinician caring for the patient is responsible for
determining the most appropriate care." MEC Approved 12/16/05

© Reviewed and modified 2005. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242
RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
RANCHO R.O.A.D.M.A.P. PHYSICAL THERAPY DEPARTMENT
(Recommendations for Orthotic Assessment, Decision-Making, And Prescription)
Lower Extremity Orthoses: Long-Leg Orthoses
Goal: Choose appropriate orthosis given patient's clinical picture and/or impairments. Page 2 of 4
Patient Population: Persons with neurological impairments who require orthoses to ambulate or to perform upright functional activities
In addition to the impairments indicated, before ordering Knee Ankle Foot Orthoses (KAFO) or Reciprocating Gait Orthoses (RGO), other factors should be
considered such as whether the patient has:
-- Sufficient ROM in Lower Extremity joints to align segments
-- The ability (including cognition) and desire to meet ambulation goals
-- Adequate cardiovascular endurance and adequate Upper Extremity (UE) and Lower Extremity (LE) strength for the intended activity, i.e. ambulation

Patient has AMBULATION TRIAL

< 3+/5 quadriceps Yes BILAT KAFO/RGO
strength bilat?
Participation Criteria
I. No contractures in hip
flexors, knee flexors, or
Patient meets
ankle plantar flexors
No Participation Criteria
II. SLR 0-110 degrees
(See Table) for Ambulation
III. Independent in all transfers
Trial with Bilateral
including wheelchair to
KAFO/RGO?3
floor
Patient has IV. Max VO2 is ≥ 20 ml/kg/min
< 3+/5 quad strength V. 50 continuous full dips in
in test side Yes parallel bars
No
and ≥ 3+/5 quad strength
in contralateral
Completion Criteria
limb?
Patient I. Come to stand with assistive
No device, independently
successfully meets
Proprioception Completion Criteria (see (3 sessions)
Yes II. Stand and walk through
intact at test knee? Table) for Ambulation Trial
Yes with Bilateral parallel bars with open
KAFO not
KAFO/RGO? hands, independently
required,
(1 session)
evaluate for Unilateral KAFO
No III. Walk with assistive device
AFO on test on test side is
No 20 continuous steps, with
side indicated1 Yes supervision only
(See AFO
(2 sessions)
Algorithm) Order bilateral
Can use unlocked KAFO or RGO4
KAFO on test side2
(refer to (b) or (c) in Person has TRIAL IS ENDED
Long Leg Orthosis knee Patient will not receive
Components for Yes
hyperextension bilateral KAFO/RGO for
type of joint) ROM? ambulation. Patient may be
re-evaluated in > 3 months

No
LONG LEG ORTHOSIS COMPONENTS
Locked knee joint Type of knee joint c) Free Knee
a) Locks (Drop or Bail) -- best for medial/lateral control or extreme
is indicated -- knee joint manually or mechanically locks valgus/varus
(refer to a) when patient reaches full knee extension -- may be used when patient has adequate
-- need to manually unlock joint to flex knee sagittal stability

b) Offset knee joint is used when patient has Materials for thigh component
knee hyperextension ROM, often with pain a) Metal uprights with leather at knee/thigh
-- knee axis is anterior to the joint line to b) Metal uprights with plastic at knee/thigh
Select type of knee joint provide an extension moment during
and materials stance and free motion during swing Anterior Tibial Shell
-- often used for patients with post -polio -- required if knee flexion contractures are present
(Refer to table at right) syndrome Plastic KAFO/RGO
-- may use drop locks if patient fatigues -- metal uprights connect plastic thigh and calf
portions

Select orthotic Footnotes:

ankle components 1. Person may not require a KAFO even with quadriceps strength < 3+/5 if hip extensor muscle strength is
(See AFO ≥ 3+/5, and he/she has full knee extension ROM, or quadriceps tone, or proprioception intact.
2. Person with knee pain may require either locked or unlocked knee joint for KAFO.
MEC Approved 12/16/05 Algorithm) 3. Ambulation with bilateral KAFO and RGO results in high energy cost (VO2 / kg / min).
4. RGO is a linked bilateral KAFO system, consisting of an additional pelvic band and cables that
allow a reciprocating gait pattern. Velocity may be slower than with unlinked bilateral KAFOs.
DISCLAIMER STATEMENT
Note: Hip flexor muscle strength of > 2/5 is required to advance the swing limb. Increased hip flexion
"The algorithm/care described in this document does not represent the only medically
muscle strength is needed to advance the leg with an orthosis. A 2# ankle weight can be used to simulate
acceptable approach. Each clinician caring for the patient is responsible for
the weight of a polypropylene KAFO.
determining the most appropriate care."

© Reviewed and modified 2005. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242
RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
RANCHO R.O.A.D.M.A.P. PHYSICAL THERAPY DEPARTMENT
(Recommendations for Orthotic Assessment, Decision-Making, And Prescription)
Lower Extremity Orthoses: Ankle Foot Orthoses (AFO)
Goal: Choose appropriate AFO given patient's clinical picture and/or impairments. Page 3 of 4
Patient Population: Persons with neurological impairments who require AFO to ambulate or to perform upright functional activities.
In addition to the impairments indicated, other factors should be considered before ordering AFO:
1) Sufficient ROM in LE joints to align lower extremity segments
2) Patient's ability (including cognition) and desire to meet goals See information on materials
3) Adequate cardiovascular endurance and adequate UE/LE strength for the intended activity, (e.g., ambulation) on attached sheet

Patient has decreased ankle strength GROUP A:

OR 1. Rigid polypropelyne AFO
impaired or absent proprioception at the 2. Metal AFO with double-
knee/ankle adjustable ankle joint (DAAJ)
Yes and poly footplate, locked
OR
ankle plantar flexor spasticity* 3. Metal AFO with DAAJ,
locked.

No GROUP B:
1. Polyarticulating AFO with
dorsiflexion (DF) stop.
No orthosis
2. Metal AFO with DAAJ and
required
poly footplate, DF stop.
3. Metal AFO with DAAJ,
Spasticity, PF contracture, or dorsiflexion stop
Select orthosis with
absent proprioception affects No
articulated ankle joint GROUP C:
foot placement during standing
or gait 1. Leaf spring AFO
2. Polyarticulating AFO with
dorsiflexion assist. Select
type of joint (see attached)
Determine if 3. Metal AFO with DAAJ and
Yes DF stop is indicated: poly footplate, DF assist
4. Metal AFO with DAAJ,
a) PF strength ≤ 4 in standing and/or dorsiflexion assist
b) Excessive ankle dorsiflexion
(knee flexion) or ankle plantar GROUP D:
Berg Balance Score < 43, flexion (knee extension) 1. Polyarticulating AFO with
or severe spacticity, or in stance plantar flexion (PF) stop.
absent proprioception No 2. Metal AFO with DAAJ and
Yes poly footplate, PF stop.
No
3. Metal AFO with DAAJ,
PF stop
Orthosis with
articulated ankle Orthosis Orthosis
joint, PF stop without DF DF = dorsiflexion
with DF stop PF = plantar flexion
Yes indicated (Group D) stop
indicated
indicated

Orthosis with locked joint and

undercut or cushioned heel is
indicated
Determine Determine
if DF assist is if DF assist is
required: required:

DF strength DF strength
is ≤ 4 No is ≤ 4
Select orthosis from Yes No
Group A Yes

Select
Select orthosis Select orthosis with
Group B with orthosis from DF assist No orthosis
Group C #2-4 Group B (Group C) required
* May include varus

DISCLAIMER STATEMENT
"The algorithm/care described in this document does not represent the only medically
acceptable approach. Each clinician caring for the patient is responsible for
determining the most appropriate care." MEC Approved 12/16/05

© Reviewed and modified 2005. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242
RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
PHYSICAL THERAPY DEPARTMENT
RANCHO R.O.A.D.M.A.P.
(Recommendations for Orthotic Assessment, Decision-Making, And Prescription)
Lower Extremity Orthoses: Patient Involvement in Decision About Intervention
Page 4 of 4
Goal: Include patient in the decision about use of a lower extremity orthosis
Patient Population: Ambulatory adult patients at RLANRC

References:
Patient has significant gait deviations1
and lower extremity orthosis(es) 1. The Pathokinesiology
recommended per AFO or Long Leg Service and the Physical
Orthoses Algorithms2 Therapy Department,
Rancho Los Amigos National
Rehabilitation Center:
Observational Gait Analysis,
Downey, CA, Los Amigos
Research and Education
Institute, Inc., 2001.

Discuss with the patient 2. Lower Extremity

Orthoses: Ankle Foot
(and family) plan to consider
Orthosis, Lower Extremity
an orthosis, including: Orthoses: Long Leg
1. Benefits and drawbacks Orthoses, Rancho Los
of orthoses Amigos National
2. Other treatment options Rehabilitation Center, 2000,
3. Patient preferences 2003.

Patient agrees to a
Yes trial with temporary
orthosis?

Institute trial with No

appropriate temporary
orthosis

Patient
acknowledges benefit
Yes No
of the orthosis and
agrees to wear it.
Orthosis not ordered.
Write prescription Consideration given to other
for orthosis* treatment options

MEC Approved 12/16/05

*Prescription is reviewed and initialed by clinical manager or
designee. DISCLAIMER STATEMENT
"The algorithm/care described in this document does not represent the only medically
acceptable approach. Each clinician caring for the patient is responsible for
determining the most appropriate care."

© Reviewed and modified 2005. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242